Literature Collection

The goal of this editorial and following supplement articles is to present different perspectives on the implementation of medical-dental-behavioral integration to provide comprehensive, whole-person care. Through a discussion of barriers to and opportunities that emerge from this type of integrated care, this editorial and supplement provide strong evidence for the importance, feasibility, and necessity of integrated health care and concept of overall health.

Recommendations for opioid agonist pharmacotherapy and against medically assisted withdrawal were based upon early reports that associated withdrawal with maternal relapse and fetal demise. Data from recent case series have called these recommendations into question. Although these data do not support an association between medically assisted withdrawal and fetal demise, relapse remains a significant clinical concern with reported rates ranging from 17% to 96% (average 48%). Given the high loss to follow-up in these studies, the actual relapse rate is likely even greater. Furthermore, while medically assisted withdrawal is being proposed as a public health strategy to reduce neonatal abstinence syndrome (NAS), current data do not support a reduction in NAS with medically assisted withdrawal relative to opioid agonist pharmacotherapy. Overall, the data do not support either benefit of medically assisted withdrawal or equivalence to opioid agonist pharmacotherapy for the maternal-newborn dyad. Medically assisted withdrawal increases the risk of maternal relapse and poor treatment engagement and does not improve newborn health. Treatment of chronic maternal disease, including opioid agonist disorder, should be directed toward optimal long-term outcome.

OBJECTIVE: Characterize the association between Medicare Accountable Care Organizations' (ACOs) behavioral health integration capability and quality and utilization among adults with serious mental illness (SMI). BACKGROUND: Controlled research supports the efficacy of integrating physical and mental health care for adults with SMI, yet little is known about the organizations integrating care and associations between integration capability and quality. METHODS: We surveyed Medicare ACOs (2017-2018 National Survey of ACOs, response rate 69%) and linked responses to 2016-2017 fee-for-service Medicare claims for beneficiaries with SMI. We examined the cross-sectional association between ACO-reported integration capability (tertiles of a 14-item index) and 7 patient-level quality and utilization outcomes. We fit generalized linear models for each outcome as a function of ACO integration capability, adjusting for ACO and beneficiary characteristics. RESULTS: Study sample included 274,928 beneficiary years (199,910 unique beneficiaries) attributed to 265 Medicare ACOs. ACOs with high behavioral health integration capability (top-tertile) served more dual-eligible beneficiaries (67.8%) than bottom-tertile (63.7%) and middle-tertile ACOs (63.3%). Most beneficiaries received follow-up 30 days after mental health hospitalization and chronic disease monitoring-exceeding national quality benchmarks-but beneficiaries receiving care from top-tertile (vs bottom-tertile) ACOs were modestly less likely to receive follow-up [-2.17 percentage points (pp), P < 0.05], diabetes monitoring (-2.19 pp, P < 0.05), and cardiovascular disease monitoring (-6.07 pp, P < 0.05). Integration capability was not correlated with utilization. CONCLUSIONS: ACOs serving adults with substantial physical and mental health needs were more likely to report comprehensive integration capability but were not yet meeting the primary care needs of many adults with SMI.

BACKGROUND: Medicare serves 65 million Americans aged 65+, with 3.7% having co-occurring mental health and substance use disorders. Despite evidence supporting integrated care, fragmented Medicare policies result in higher readmissions and lower treatment completion rates for this vulnerable population. PURPOSE: To analyze Medicare policies using the Integration Continuum Framework and identify nursing practice and policy implications for older adults with dual diagnoses. METHODS: Systematic review of Medicare policy documents (2010-2023) analyzed through the Integration Continuum Framework across clinical, financial, and administrative dimensions. DISCUSSION: Medicare policies predominantly reflect minimal integration (Levels 1-2). Only 17.3% of beneficiaries with co-occurring disorders receive coordinated care, requiring visits to 3.7 providers across 2.8 facilities compared to 1.9 providers at 1.6 facilities for single diagnoses. The Collaborative Care Model achieves Level 3 integration but excludes substance use disorders, limiting comprehensive care. CONCLUSION: Medicare's fragmented approach creates significant coordination challenges. Nurses are uniquely positioned to bridge these gaps through screening protocols, care navigation, and leadership initiatives. Policy reforms including expanding the Collaborative Care Model to include substance use disorders, eliminating same-day billing restrictions, and streamlining documentation represent pathways toward comprehensive Level 4-5 integration, ultimately improving outcomes for older adults with dual diagnoses.